Healthcare Provider Details

I. General information

NPI: 1699925370
Provider Name (Legal Business Name): LEANN TYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W COMMERCE
YUKON OK
73099
US

IV. Provider business mailing address

2808 S CHARLES DR
EL RENO OK
73036-6121
US

V. Phone/Fax

Practice location:
  • Phone: 405-354-1927
  • Fax:
Mailing address:
  • Phone: 405-262-6299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number116482
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: